By Noel Plumridge
09 July 2009
Conservative health policies hark back to the days of family doctors and GP fundholding. They also promise to increase funding and scrap targets in favour of outcomes. But what do all these pledges add up to, asks Noel Plumridge
Each year, in the early summer, NHS bosses assemble for the annual conference of the NHS Confederation. Confed, as it’s informally known, is often the venue for significant announcements, and this year’s gathering in Liverpool was no exception.
NHS chief executive David Nicholson presented a particularly gloomy picture of the strategic financial outlook. Much gossip surrounded Mark Britnell, rising star of NHS management and figurehead of the Department of Health’s high-profile, ‘world-class commissioning’ initiative, whose imminent departure for consultancy KPMG was announced.
But both were upstaged by shadow health secretary Andrew Lansley, who used the BBC’s Today radio programme to announce: ‘We are going to increase the resources for the NHS [along with international development and schools]. But that does mean over three years after 2011 a 10% reduction in the expenditure limits for other departments.’
Lansley then went on to the Liverpool conference, where he criticised the NHS’s command-and-control approach to management and praised Conservative leader David Cameron and shadow chancellor George Osborne for ‘going out on a limb’ to guarantee the NHS budget. He said his three priorities would be equity, efficiency and excellence.
This was the cue for a public debate on the precise meaning of Lansley’s announcement (would that be a real-terms or a cash increase?) and the true nature of public spending projections (definitely cash, not real-terms) allowing the prime minister to boast of Labour ‘investment’. On whether the present government would match the Conservative commitment, newly appointed Health Secretary Andy Burnham wouldn’t commit, observing that ‘the NHS isn’t immune to what is happening in the wider world’ and ‘can’t and shouldn’t expect’ to see the recent pattern of funding growth continue.
Meanwhile, the Labour Party began calculating the impact of a 10% cut in the education and police budgets (‘the equivalent of losing 44,130 teachers… 15,000 police officers… 32,000 university places…’) Conservative frontbenchers began to reflect on the implications. And Lansley claimed that he had been misunderstood.
The link between funding levels and Conservative health policy, however, has remained opaque throughout the debate. Vital questions remain. If health spending were indeed to grow under a future Conservative government, where would the money go? Would it be enough? And how would ‘equity, efficiency and excellence’ translate into patient experience?
Current Conservative health policy is best defined in two documents, Renewal: plan for a better NHS and Delivering some of the best health in Europe, both published in 2008. Supplemented by comments from leading Tories – especially Lansley, who appears increasingly secure in the shadow health role – clear themes emerge.
First, there is a pledge to end an alleged culture of top-town control and management by targets, and to establish patient outcomes as the criterion of success. Targets are seen as bad: they have distorted priorities and demoralised clinicians. Management fixation with meeting them has been partly blamed for the problems at Stafford Hospital, whose failings in patient care and high death rates were slated by the Healthcare Commission in March. Renewal offers several specific commitments:
These aims look curiously like targets by another name, albeit targets for the effectiveness of health care interventions and public health initiatives, rather than the ‘access targets’ of the past ten years that have made such a dramatic difference to NHS waiting lists and waiting times. So what’s the difference?
According to Renewal: ‘Outcomes are fundamentally different from targets because health care professionals focused on outcomes are not being commanded by bureaucrats to adopt specified procedures or processes to achieve results.’ This leaves open the question of who will collect and monitor performance on outcomes, and take action where necessary?
Are these pledges actually achievable? The major improvements in access to health care that have been achieved since 2003 have required a combination of three factors: explicit targets, such as a maximum of 18 weeks from presentation to treatment; ‘performance management’ bordering on the brutal; and considerable financial investment in additional capacity.
But the managerial and clinical stamina for targets has wilted – hence the rationale for politicians distancing themselves from them (NHS employees share over a million votes between them) – and the financial imperative is now rapid retrenchment. Current Department of Health emphasis is on efficiency (‘productivity’) rather than effectiveness. And the combination of moving targets (volatility is in the nature of averages), public health gain (requiring substantial lifestyle changes in the population at large) and greater patient satisfaction (notoriously difficult to predict or even to measure) represents a challenging work programme.
Then there are pledges on ‘patient choice’, covering choice of hospital; choice of doctor; access to single rooms in NHS hospitals; individual budgets for patients with long-term conditions; and choice of a primary care commissioner – not a primary care trust, but a GP practice.
None of this is radically different from Labour policy, although the DoH appears to be quietly edging away from choice and personalisation, presumably because they do not come cheap. They were notably absent from Chancellor Alistair Darling’s April budget.
It is worth noting the emphasis that Conservative policy places on that paterfamilias, the traditional GP family doctor. ‘We value… the “relationship medicine” which is one of the best features of our GP care,’ states Renewal. ‘We have never supported Labour’s plans to replace family doctor surgeries with big, impersonal “polyclinics”.’
In the same spirit of localism, cuts in maternity and accident and emergency services are also explicitly ruled out.
Perhaps conservatism has always had a soft spot for authority figures (there are also generous promises to engage an extra 4,200 health visitors) but the social context is changing. The independent contractor GP practice, mainstay of NHS primary care since 1948, faces a dual threat, especially in urban areas: from demographics within the medical profession, and from external commercial interests.
In the case of demographics, policy statements are unlikely to turn back the tide of change. A recent report from the Royal College of Physicians noted that women will make up the majority of GPs by 2013. Male or female, fewer and fewer doctors are willing to commit to the lifestyle associated with traditional relationship medicine: they want evenings off and holidays. A growing number prefer salaried employment.
Meanwhile, there has been growing pressure, particularly in cities, to open up primary care provision to competition from pharmacies, supermarkets and other commercial enterprises. These firms are all natural Tory allies. In recessionary times this pressure might mount: secure streams of government income represent a rare opportunity for growth. And if the ‘polyclinic’ is now seen as bad, that’s a view seemingly shared by Labour. In Lord Darzi’s 2008 report on the future of the NHS, it was the clinic that dared not speak its name. Yet part of its initial attractiveness was its inherent efficiency, a need that has certainly not diminished.
Primary care medicine represents a rich dilemma for Conservatives. Support the traditional professional, or encourage competition from big business? Thus far Lansley has been able to sit on the fence.
Faith in GPs extends to their role in commissioning. Renewal effectively promises a return to the GP fundholding policy abandoned by Labour in 1997, but partly reinstated in recent times under the banner of practice-based commissioning.
‘Budget-holding is a natural guarantee of efficiency, ensuring money follows the patient,’ states the policy document. ‘GPs – rather than remote managers – should be responsible for reconciling the available resources with clinical priorities and patient choice.’
Yet practice-based commissioning has struggled to gain support. Many GPs are reluctant to don the rationing mantle, and further incentives would be costly and perhaps provocative given their current remuneration levels. Such faith in GP commissioning as the antidote to provider-led demand, for a budget that represents some 9% of gross domestic product and in a climate of heroic cost saving expectations, might prove brave.
This reversion to GP fundholding, along with related plans such as greater autonomy for local authorities and hostility to non-clinical ‘bureaucrats’, could spell bad news for England’s 152 primary care trusts, and perhaps also its ten strategic health authorities.
There is no such threat to the NHS provider configuration, with explicit support for all current NHS trusts and the provider arms of PCTs to become foundation trusts, seen by Lansley as a main driver of reform. In reality, the development of foundation trusts has finally brought former health secretary Kenneth Clarke’s vision of self-governing hospitals to fruition, 20 years on. Monitor, the independent regulator of foundation trusts, can expect to see its role strengthened, with a ‘statutory duty to be the economic regulator for the health care sector’.
In fact, with duties including the promotion of competition, safety, quality, efficiency and economy, ensuring workforce supply and promoting research and development, one begins to wonder what the Department of Health will be doing.
The Conservatives support operational independence for the NHS, including the creation of an independent board and a constitution. There are echoes here of the NHS Policy Board of the 1990s. Support is also there for the role of the Care Quality Commission (though not extending to the licensing of GP practices), the creation of a national consumer voice, Healthwatch, and a genuine market place for the information that supports choice and care standards.
What is one to make of the emerging policy package and its implied priorities? Critics and opponents have been quick to point out a lack of pound signs against the pledges, and to question their affordability. It would be unreasonable to expect detailed costs at this stage; yet promises of single rooms and ready access to all clinically proven drugs must come with substantial price tags. How will they be financed? Even if the implied efficiencies can be achieved, will the overall economic outlook allow the planned ring-fencing of health budgets to be sustained?
This might become a real conflict when individualism and choice (with its inherent cost of surplus capacity) are constrained by operational budgets and fiscal reality. In other times, independent sector provision would be seen as a natural alternative. But under Cameron, with his personal history and genuine familiarity with NHS services, that old reflex reversion to non-NHS care appears less likely to continue.
One further conclusion might be that, for all the emphasis on what’s different, there is much within this package that represents substantial continuity with current DoH policy. An end to management by targets; individual patient budgets; GP-led commissioning; operational independence.
For many NHS managers, it could almost be business as usual. The trick will be achieving these aspirations in an increasingly chilly economic context.
Noel Plumridge is a former NHS finance director and the author of CIPFA’s Payment by results
09 July 2009
Conservative health policies hark back to the days of family doctors and GP fundholding. They also promise to increase funding and scrap targets in favour of outcomes. But what do all these pledges add up to, asks Noel Plumridge
Each year, in the early summer, NHS bosses assemble for the annual conference of the NHS Confederation. Confed, as it’s informally known, is often the venue for significant announcements, and this year’s gathering in Liverpool was no exception.
NHS chief executive David Nicholson presented a particularly gloomy picture of the strategic financial outlook. Much gossip surrounded Mark Britnell, rising star of NHS management and figurehead of the Department of Health’s high-profile, ‘world-class commissioning’ initiative, whose imminent departure for consultancy KPMG was announced.
But both were upstaged by shadow health secretary Andrew Lansley, who used the BBC’s Today radio programme to announce: ‘We are going to increase the resources for the NHS [along with international development and schools]. But that does mean over three years after 2011 a 10% reduction in the expenditure limits for other departments.’
Lansley then went on to the Liverpool conference, where he criticised the NHS’s command-and-control approach to management and praised Conservative leader David Cameron and shadow chancellor George Osborne for ‘going out on a limb’ to guarantee the NHS budget. He said his three priorities would be equity, efficiency and excellence.
This was the cue for a public debate on the precise meaning of Lansley’s announcement (would that be a real-terms or a cash increase?) and the true nature of public spending projections (definitely cash, not real-terms) allowing the prime minister to boast of Labour ‘investment’. On whether the present government would match the Conservative commitment, newly appointed Health Secretary Andy Burnham wouldn’t commit, observing that ‘the NHS isn’t immune to what is happening in the wider world’ and ‘can’t and shouldn’t expect’ to see the recent pattern of funding growth continue.
Meanwhile, the Labour Party began calculating the impact of a 10% cut in the education and police budgets (‘the equivalent of losing 44,130 teachers… 15,000 police officers… 32,000 university places…’) Conservative frontbenchers began to reflect on the implications. And Lansley claimed that he had been misunderstood.
The link between funding levels and Conservative health policy, however, has remained opaque throughout the debate. Vital questions remain. If health spending were indeed to grow under a future Conservative government, where would the money go? Would it be enough? And how would ‘equity, efficiency and excellence’ translate into patient experience?
Current Conservative health policy is best defined in two documents, Renewal: plan for a better NHS and Delivering some of the best health in Europe, both published in 2008. Supplemented by comments from leading Tories – especially Lansley, who appears increasingly secure in the shadow health role – clear themes emerge.
First, there is a pledge to end an alleged culture of top-town control and management by targets, and to establish patient outcomes as the criterion of success. Targets are seen as bad: they have distorted priorities and demoralised clinicians. Management fixation with meeting them has been partly blamed for the problems at Stafford Hospital, whose failings in patient care and high death rates were slated by the Healthcare Commission in March. Renewal offers several specific commitments:
- by 2015, five-year survival rates for cancer in excess of European Union averages
- by 2015, premature mortality from stroke and heart disease below EU averages
- by 2020, premature mortality from lung disease below EU averages
- mortality amenable to health care brought down to the level of comparable countries.
-
These aims look curiously like targets by another name, albeit targets for the effectiveness of health care interventions and public health initiatives, rather than the ‘access targets’ of the past ten years that have made such a dramatic difference to NHS waiting lists and waiting times. So what’s the difference?
According to Renewal: ‘Outcomes are fundamentally different from targets because health care professionals focused on outcomes are not being commanded by bureaucrats to adopt specified procedures or processes to achieve results.’ This leaves open the question of who will collect and monitor performance on outcomes, and take action where necessary?
Are these pledges actually achievable? The major improvements in access to health care that have been achieved since 2003 have required a combination of three factors: explicit targets, such as a maximum of 18 weeks from presentation to treatment; ‘performance management’ bordering on the brutal; and considerable financial investment in additional capacity.
But the managerial and clinical stamina for targets has wilted – hence the rationale for politicians distancing themselves from them (NHS employees share over a million votes between them) – and the financial imperative is now rapid retrenchment. Current Department of Health emphasis is on efficiency (‘productivity’) rather than effectiveness. And the combination of moving targets (volatility is in the nature of averages), public health gain (requiring substantial lifestyle changes in the population at large) and greater patient satisfaction (notoriously difficult to predict or even to measure) represents a challenging work programme.
Then there are pledges on ‘patient choice’, covering choice of hospital; choice of doctor; access to single rooms in NHS hospitals; individual budgets for patients with long-term conditions; and choice of a primary care commissioner – not a primary care trust, but a GP practice.
None of this is radically different from Labour policy, although the DoH appears to be quietly edging away from choice and personalisation, presumably because they do not come cheap. They were notably absent from Chancellor Alistair Darling’s April budget.
It is worth noting the emphasis that Conservative policy places on that paterfamilias, the traditional GP family doctor. ‘We value… the “relationship medicine” which is one of the best features of our GP care,’ states Renewal. ‘We have never supported Labour’s plans to replace family doctor surgeries with big, impersonal “polyclinics”.’
In the same spirit of localism, cuts in maternity and accident and emergency services are also explicitly ruled out.
Perhaps conservatism has always had a soft spot for authority figures (there are also generous promises to engage an extra 4,200 health visitors) but the social context is changing. The independent contractor GP practice, mainstay of NHS primary care since 1948, faces a dual threat, especially in urban areas: from demographics within the medical profession, and from external commercial interests.
In the case of demographics, policy statements are unlikely to turn back the tide of change. A recent report from the Royal College of Physicians noted that women will make up the majority of GPs by 2013. Male or female, fewer and fewer doctors are willing to commit to the lifestyle associated with traditional relationship medicine: they want evenings off and holidays. A growing number prefer salaried employment.
Meanwhile, there has been growing pressure, particularly in cities, to open up primary care provision to competition from pharmacies, supermarkets and other commercial enterprises. These firms are all natural Tory allies. In recessionary times this pressure might mount: secure streams of government income represent a rare opportunity for growth. And if the ‘polyclinic’ is now seen as bad, that’s a view seemingly shared by Labour. In Lord Darzi’s 2008 report on the future of the NHS, it was the clinic that dared not speak its name. Yet part of its initial attractiveness was its inherent efficiency, a need that has certainly not diminished.
Primary care medicine represents a rich dilemma for Conservatives. Support the traditional professional, or encourage competition from big business? Thus far Lansley has been able to sit on the fence.
Faith in GPs extends to their role in commissioning. Renewal effectively promises a return to the GP fundholding policy abandoned by Labour in 1997, but partly reinstated in recent times under the banner of practice-based commissioning.
‘Budget-holding is a natural guarantee of efficiency, ensuring money follows the patient,’ states the policy document. ‘GPs – rather than remote managers – should be responsible for reconciling the available resources with clinical priorities and patient choice.’
Yet practice-based commissioning has struggled to gain support. Many GPs are reluctant to don the rationing mantle, and further incentives would be costly and perhaps provocative given their current remuneration levels. Such faith in GP commissioning as the antidote to provider-led demand, for a budget that represents some 9% of gross domestic product and in a climate of heroic cost saving expectations, might prove brave.
This reversion to GP fundholding, along with related plans such as greater autonomy for local authorities and hostility to non-clinical ‘bureaucrats’, could spell bad news for England’s 152 primary care trusts, and perhaps also its ten strategic health authorities.
There is no such threat to the NHS provider configuration, with explicit support for all current NHS trusts and the provider arms of PCTs to become foundation trusts, seen by Lansley as a main driver of reform. In reality, the development of foundation trusts has finally brought former health secretary Kenneth Clarke’s vision of self-governing hospitals to fruition, 20 years on. Monitor, the independent regulator of foundation trusts, can expect to see its role strengthened, with a ‘statutory duty to be the economic regulator for the health care sector’.
In fact, with duties including the promotion of competition, safety, quality, efficiency and economy, ensuring workforce supply and promoting research and development, one begins to wonder what the Department of Health will be doing.
The Conservatives support operational independence for the NHS, including the creation of an independent board and a constitution. There are echoes here of the NHS Policy Board of the 1990s. Support is also there for the role of the Care Quality Commission (though not extending to the licensing of GP practices), the creation of a national consumer voice, Healthwatch, and a genuine market place for the information that supports choice and care standards.
What is one to make of the emerging policy package and its implied priorities? Critics and opponents have been quick to point out a lack of pound signs against the pledges, and to question their affordability. It would be unreasonable to expect detailed costs at this stage; yet promises of single rooms and ready access to all clinically proven drugs must come with substantial price tags. How will they be financed? Even if the implied efficiencies can be achieved, will the overall economic outlook allow the planned ring-fencing of health budgets to be sustained?
This might become a real conflict when individualism and choice (with its inherent cost of surplus capacity) are constrained by operational budgets and fiscal reality. In other times, independent sector provision would be seen as a natural alternative. But under Cameron, with his personal history and genuine familiarity with NHS services, that old reflex reversion to non-NHS care appears less likely to continue.
One further conclusion might be that, for all the emphasis on what’s different, there is much within this package that represents substantial continuity with current DoH policy. An end to management by targets; individual patient budgets; GP-led commissioning; operational independence.
For many NHS managers, it could almost be business as usual. The trick will be achieving these aspirations in an increasingly chilly economic context.
Noel Plumridge is a former NHS finance director and the author of CIPFA’s Payment by results
