Commission quite possible

9 May 08
NIALL DICKSON | Just as the NHS celebrates its sixtieth birthday, health minister Lord Darzi will publish his long-awaited review — described at its launch by Health Secretary Alan Johnson as a ‘once in a generation opportunity’.

Just as the NHS celebrates its sixtieth birthday, health minister Lord Darzi will publish his long-awaited review — described at its launch by Health Secretary Alan Johnson as a ‘once in a generation opportunity’.

For Darzi, the pressure is on. To meet expectations he will have to produce a vision for health care that will stand for at least the next decade.

Sadly, the excitement around such plans is not always matched by their implementation. Even when they are pushed through, the moment of glory soon passes. The guiding strategic document for the first decade of this millennium, the NHS Plan, has already faded from the collective memory to the point where the prime minister did not even refer to it in his major speech on health earlier this year.

But there is one controversial reform, initially abandoned, that might yet be revived. In the summer of 2005, the then NHS chief executive, Sir Nigel (now Lord) Crisp, provoked protest when he slipped out Commissioning a patient-led NHS in the aftermath of Labour’s election victory. This document heralded fundamental structural reform, including cutting the number of strategic health authorities (from 28 to ten) and primary care trusts (eventually cut from 303 to 152).

More importantly, the document spelt out more clearly than before the strategic ambition of the government to move the NHS from being a state-run set of monopoly providers to a commissioning function operating at arm’s length from a range of different organisations that would contract to run NHS services.

The logical consequence was that PCTs should stop providing services themselves and instead focus on the real task in hand: commissioning.

The proposals attracted widespread criticism, much of it justified not because the ideas were wrong but for the inept way they were handled. Few doubt that this fiasco, together with the NHS’s financial problems that year, contributed to Crisp’s departure.

But as we approach Darzi’s review, there is an opportunity to separate the handling from the substance of this matter. Because the thinking behind the proposal to separate PCTs from their provider arms was most certainly correct.

Set aside the need to give PCT staff and organisations time and support to reshape and reform. Set aside too the need first to sort out the terms and conditions issues for staff who might find themselves transferring into new organisations. These are matters that can be solved.

The underlying issue is clarity about what sort of NHS the government is trying to create. The NHS’s success now rests on effective commissioning, and if PCTs are to oversee hundreds of millions of pounds-worth of business, their first task must be to concentrate on that challenging role without the distraction of providing services directly to patients.

It is also hard to see how PCTs can be impartial commissioners if they have a vested interest in a major organisation that is in the business of providing services. Instead, the model suggests that NHS-funded health care should be commissioned independently, not in the interests of provider organisations but in the interests of local patients and citizens. It should then be delivered by a range of organisations, most of them not-for-profit outfits which, while regulated, will be responsible for their own success and failure.

This is the model the health service in England has adopted and effort is now going into making commissioning work — in the Department of Health’s latest buzz phrase, officials are seeking to create ‘world-class commissioners’. There are perhaps five to ten years to demonstrate whether this approach works, but it will not if it is adopted half-heartedly. Let us hope Darzi is brave. He needs to send out that signal, and suggest practical steps to enable provider functions to be set free.

His review will need to be clear about the government’s commitment to this goal, and the levers it needs to put in place to achieve it. There is also an urgent need for clarity on the developing market so competition can be regulated to sustain the NHS and serve patients’ interests.

No-one is talking here about a free market — health care will always be regulated — but if a market or quasi-market is to be effective, obvious questions need to be addressed. As well as explicit commitment from the government to development of the market, there needs to be guidance on what happens to failing organisations, and more work on ensuring that professionals and patients have the information they need to measure service quality and make choices.

What we really want to see in the Darzi review is a commitment to follow through, to put in place the right incentives to make NHS organisations safer, more responsive and more accountable to local people. If Darzi can meet this challenge, he might defy the critics and deliver Johnson’s ‘once in a generation’ opportunity.

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