By David Williams
15 June 2010
If you asked Professor Chris Ham what the top health priority should be in 2010, he wouldn’t suggest handing commissioning powers over to GPs at the earliest opportunity.
But Health Secretary Andrew Lansley has set out ambitious plans to do just that in his July 12 white paper – which, in the process, will completely rearrange the internal market system that is the financial basis for the NHS.
Lansley’s plan to give GP consortiums about £80bn a year – four-fifths of the NHS budget – to purchase hospital treatments would kill off primary care trusts, which currently control that cash. The radical shake-up is being billed as the biggest in 60 years and would also lead to the scrapping of strategic health authorities.
However, Ham – who took over from Niall Dickson as chief executive of the King’s Fund in April – identifies a different set of priorities.
And there can be few more qualified to speak than him. With more than 30 years’ experience in health policy, he has advised the World Health Organisation and governments across the globe. Ham also used to run the Department of Health’s strategy unit and, until recently, was a fellow at the Nuffield Trust. He retains a position at the University of Birmingham’s Health Services Management Centre.
The organisation he now leads occupies a ‘unique space within health care in this country’, and has an international reputation, according to Andy McKeon, the Audit Commission’s managing director for health.
The King’s Fund supports health providers in implementing policy on the ground, and offers professional support to clinicians and health managers. The think-tank is also rare in that it has no political leanings. ‘The chief executive of the King’s Fund has always had an influential national voice,’ adds McKeon.
Ham asserts his command of the subject lightly, and has a lively, affable presence. Although quietly spoken, he does not shy from expressing serious reservations about aspects of government health care policy – or of exposing its apparent contradictions.
Within a couple of minutes of sitting down, Ham targets Lansley’s pledge to prevent the closure of hospitals and accident & emergency units, saying this is at odds with the imperative to improve care. ‘Changes are necessary and desirable,’ he argues. ‘Lansley has been very clear that quality and outcomes are important… The contradiction is, can you pursue that policy at the same time as saying no to reconfigurations that aren’t supported locally?’
And, rather than sweeping reforms to commissioning, he tells Public Finance: ‘The first priority has to be the [Department of Health initiative] Quality, Innovation, Productivity and Prevention programme’. This, he says, is essential for the NHS to meet its target of £15bn–£20bn savings by 2014, which was set by the previous government.
‘There are opportunities to become more productive, in procurement, clinical practice or back-office functions’, but the challenge of putting Qipp into practice remains. ‘This isn’t sexy stuff,’ Ham says, ‘but there are questions over whether the capacity exists to make it happen.’
He suggests the focus on large-scale reform – which is exactly the sort of ‘sexy stuff’ that could ensure a health secretary’s place in history – could direct efforts away from generating savings through smarter working.
Early interventions to stop people becoming more expensively sick in the future is central to a cheaper yet more effective NHS, he says. Today’s obesity, smoking and alcohol abuse threaten to create a long-term burden of ill health that would be ‘unsupportable in a universal, tax-funded NHS’.
To that end, he is impressed by Lansley’s recognition of the importance of the subject – a public health white paper is expected before the end of the year – and is unflustered by the pre-election pledge to relaunch the ministry as the Department for Public Health.
But inevitably the government must be judged on what it actually does. There is little evidence so far that it will be so eager to take the regulatory approach that led to the ban on smoking in work places – which Ham describes as ‘probably the most important public health measure in the past 20 or 30 years’.
Lansley has already promised not to further regulate the junk food industry as long as it agrees to pay for healthy eating campaigns. This provokes a knowing chuckle from Ham. He says that the government has instead set itself the challenge of using more libertarian methods of nudging people into acting differently.
Exactly how the focus on public health fits into the GP commissioning plan will probably not become apparent until the public health white paper comes out.
Overall, Ham is a longstanding critic of NHS commissioning, often describing it as the weak link in the system. He argues that every patient’s needs are different and health care packages are much harder to draw up than, say, deals between a car manufacturer and a component supplier.
Ham agrees that involving GPs is a good idea, as they know their patients’ needs better than anyone else. However, he says the move could ‘muddy the waters’ by complicating their role. And it threatens to create conflicts of interest – in which practitioners could be tempted to pay themselves to do work in-house, against the interests of the patient.
A further concern is that it is not clear how GP-led commissioning can make health and social care services more coherent as GPs have little experience commissioning social care.
There could also be an accountability gap, Ham says. Who ensures that what is commissioned gives results for patients?
Crucially, he adds, there must be oversight of the whole health care system in a local area. Ham pledges to use his time leading the King’s Fund to ‘fly the flag for a systems approach’, which he links back to the need for GP consortiums to be accountable.
‘We’ve given too much attention in the past decade to assessing organisational performance, and we’ve neglected the bigger challenge of how local systems are working to benefit the local population.
‘My worry is that you might end up with a foundation trust being successful, but bankrupting commissioners, or commissioners being successful but creating deficits in FTs.’
Ham argues that a tier of around 50 strategic PCTs would have been desirable. ‘You need to be clear who are the system leaders in the NHS. You need a body, like a PCT, that focuses on public health, on populations – that supports FTs and GPs to make sensible changes.’
But Lansley plans for councils to take on the role. Ham says local authorities can in theory fill the vacuum, but ‘they will need to quickly strengthen their expertise in NHS issues to be able to do so effectively’.
And, amid all this reform, one thing we can be sure of is that however much the NHS is going to be squeezed in the coming years, councils will be under far more pressure. Once again, the future of public services will depend on their ability to cope with the cuts that are about to be inflicted on them.
15 June 2010
This week’s all-change health white paper might make for flashy headlines. But the new head of the King’s Fund has doubts about the detail. Chris Ham talks to David Williams
If you asked Professor Chris Ham what the top health priority should be in 2010, he wouldn’t suggest handing commissioning powers over to GPs at the earliest opportunity.
But Health Secretary Andrew Lansley has set out ambitious plans to do just that in his July 12 white paper – which, in the process, will completely rearrange the internal market system that is the financial basis for the NHS.
Lansley’s plan to give GP consortiums about £80bn a year – four-fifths of the NHS budget – to purchase hospital treatments would kill off primary care trusts, which currently control that cash. The radical shake-up is being billed as the biggest in 60 years and would also lead to the scrapping of strategic health authorities.
However, Ham – who took over from Niall Dickson as chief executive of the King’s Fund in April – identifies a different set of priorities.
And there can be few more qualified to speak than him. With more than 30 years’ experience in health policy, he has advised the World Health Organisation and governments across the globe. Ham also used to run the Department of Health’s strategy unit and, until recently, was a fellow at the Nuffield Trust. He retains a position at the University of Birmingham’s Health Services Management Centre.
The organisation he now leads occupies a ‘unique space within health care in this country’, and has an international reputation, according to Andy McKeon, the Audit Commission’s managing director for health.
The King’s Fund supports health providers in implementing policy on the ground, and offers professional support to clinicians and health managers. The think-tank is also rare in that it has no political leanings. ‘The chief executive of the King’s Fund has always had an influential national voice,’ adds McKeon.
Ham asserts his command of the subject lightly, and has a lively, affable presence. Although quietly spoken, he does not shy from expressing serious reservations about aspects of government health care policy – or of exposing its apparent contradictions.
Within a couple of minutes of sitting down, Ham targets Lansley’s pledge to prevent the closure of hospitals and accident & emergency units, saying this is at odds with the imperative to improve care. ‘Changes are necessary and desirable,’ he argues. ‘Lansley has been very clear that quality and outcomes are important… The contradiction is, can you pursue that policy at the same time as saying no to reconfigurations that aren’t supported locally?’
And, rather than sweeping reforms to commissioning, he tells Public Finance: ‘The first priority has to be the [Department of Health initiative] Quality, Innovation, Productivity and Prevention programme’. This, he says, is essential for the NHS to meet its target of £15bn–£20bn savings by 2014, which was set by the previous government.
‘There are opportunities to become more productive, in procurement, clinical practice or back-office functions’, but the challenge of putting Qipp into practice remains. ‘This isn’t sexy stuff,’ Ham says, ‘but there are questions over whether the capacity exists to make it happen.’
He suggests the focus on large-scale reform – which is exactly the sort of ‘sexy stuff’ that could ensure a health secretary’s place in history – could direct efforts away from generating savings through smarter working.
Early interventions to stop people becoming more expensively sick in the future is central to a cheaper yet more effective NHS, he says. Today’s obesity, smoking and alcohol abuse threaten to create a long-term burden of ill health that would be ‘unsupportable in a universal, tax-funded NHS’.
To that end, he is impressed by Lansley’s recognition of the importance of the subject – a public health white paper is expected before the end of the year – and is unflustered by the pre-election pledge to relaunch the ministry as the Department for Public Health.
But inevitably the government must be judged on what it actually does. There is little evidence so far that it will be so eager to take the regulatory approach that led to the ban on smoking in work places – which Ham describes as ‘probably the most important public health measure in the past 20 or 30 years’.
Lansley has already promised not to further regulate the junk food industry as long as it agrees to pay for healthy eating campaigns. This provokes a knowing chuckle from Ham. He says that the government has instead set itself the challenge of using more libertarian methods of nudging people into acting differently.
Exactly how the focus on public health fits into the GP commissioning plan will probably not become apparent until the public health white paper comes out.
Overall, Ham is a longstanding critic of NHS commissioning, often describing it as the weak link in the system. He argues that every patient’s needs are different and health care packages are much harder to draw up than, say, deals between a car manufacturer and a component supplier.
Ham agrees that involving GPs is a good idea, as they know their patients’ needs better than anyone else. However, he says the move could ‘muddy the waters’ by complicating their role. And it threatens to create conflicts of interest – in which practitioners could be tempted to pay themselves to do work in-house, against the interests of the patient.
A further concern is that it is not clear how GP-led commissioning can make health and social care services more coherent as GPs have little experience commissioning social care.
There could also be an accountability gap, Ham says. Who ensures that what is commissioned gives results for patients?
Crucially, he adds, there must be oversight of the whole health care system in a local area. Ham pledges to use his time leading the King’s Fund to ‘fly the flag for a systems approach’, which he links back to the need for GP consortiums to be accountable.
‘We’ve given too much attention in the past decade to assessing organisational performance, and we’ve neglected the bigger challenge of how local systems are working to benefit the local population.
‘My worry is that you might end up with a foundation trust being successful, but bankrupting commissioners, or commissioners being successful but creating deficits in FTs.’
Ham argues that a tier of around 50 strategic PCTs would have been desirable. ‘You need to be clear who are the system leaders in the NHS. You need a body, like a PCT, that focuses on public health, on populations – that supports FTs and GPs to make sensible changes.’
But Lansley plans for councils to take on the role. Ham says local authorities can in theory fill the vacuum, but ‘they will need to quickly strengthen their expertise in NHS issues to be able to do so effectively’.
And, amid all this reform, one thing we can be sure of is that however much the NHS is going to be squeezed in the coming years, councils will be under far more pressure. Once again, the future of public services will depend on their ability to cope with the cuts that are about to be inflicted on them.
