10 February 2006
The government's white paper on health has outlined how it proposes to tackle inequalities of care, but fudges some crucial issues over funding and provision, which may undermine its effectiveness
Last week's white paper Our health, our care, our say is an important step towards solving a clear problem — the most deprived areas with the greatest health care needs also have the worst provision.
The paper tackles some issues but its significant flaw is that others are deferred.
For example, it announces a redistribution of funds in favour of under-doctored areas. However, how this extra funding is spent is more important than how much the government is willing to provide. What deprived areas really need are services capable of spending this money. Recognising the difficulty some primary care trusts face in commissioning new services, the Department of Health will lead a national procurement initiative to help them with this task.
There is also a welcome emphasis on including third sector and for-profit firms in commissioning decisions, although it has yet to be seen whether the commissioning system can attract such providers without a radical overhaul.
Deprived areas face the worst health problems, their GPs a tougher job. A Social Market Foundation report on public pay showed that GPs would need an extra £4,000 annually to encourage them to such areas.
The paper's redistribution of funds makes this possible — however, no guidance is given to this effect.
A typical 9,000 patient surgery in an area of median deprivation would have to spend only 7% of the extra funding the white paper has set aside to secure the services of an extra GP and bring provision up to the national median.
To bring a severely deprived surgery towards the staffing levels enjoyed in prosperous counties would require at least 15% of its extra funding.
Although this will constrain the amount of increased funding spent on medicines and procedures, it is a crucial step if there is to be any health improvement in deprived areas. Extra money for treatments will have no effect on health outcomes if there is no one available to deliver it.
While local wage flexibility is not explicit in the paper, it must be realised if the paper's radical agenda to improve equality of service is to be successful.
A reform that is to be welcomed is the paper's move to attach 100% of funding to patients, rather than the current 70%. This will remedy the difficulties faced by expanding surgeries. Practices will not only be enabled, but financially encouraged, to take on new patients.
This emphasis is well placed — the Social Market Foundation's Choice: the evidence report showed that a precondition of a successful choice-based system is funding following the user. Yet, at the same time, the government will not scrap the Minimum Practice Income Guarantee, which prevents practice incomes declining below 2004 levels.
Maintaining this in a system of choice will lead to increasingly unproductive expenditure, yet the government will only 'ask NHS employers to consider the MPIG' in the light of the paper.
The success of these proposals for driving improvement through increased choice rests on persuading the General Practice Committee to abandon the MPIG. This is a problem deferred.
Other significant issues have not been addressed. For example, dealing with practice failure will be extremely important. Less popular practices will face declining resources, and vulnerable patients could be stranded in struggling surgeries.
The SMF called for a clear system of intervention in failing practices: the PCT should first assist a failing surgery; there should be opportunities for merger with successful practices; at the extreme, a failing practice would have to be taken over.
Failing to consider constructive exit options suggests the government either refuses to face the implications of its policies, or does not think its reforms will lead to major change.
Another interesting proposal will allow residents to petition their PCTs if they are unhappy with current provision. Such a mechanism is necessary to link supply to demand.
However, the white paper does not go far enough, and leaves the PCT central to the process. PCTs' uneven commissioning ability has always been central to our problems of under-supply, yet the paper safeguards their gate-keeping role.
Under the white paper, PCTs can reject residents' petitions. A better approach would have been to allow a sufficiently large petition to bypass the PCT, and allow areas with a certain proportion of closed lists to be awarded automatically with new tenders.
This would overcome the conflicts between PCTs and existing service providers that negate citizens' ability to demand the services they pay for.
The white paper includes several innovative proposals to promote patient choice and equity of access. However, the few key areas where the government has resorted to half-measures are likely to undermine its efficacy in meeting its objectives.
Ann Rossiter is the director of the Social Market Foundation
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