White paper could set the NHS back three years, by James Gubb

12 Jul 10
Plans in the health white paper to transfer responsibility for commissioning from primary care trusts to GPs universally and at a rapid pace must be cause for concern. They could set the NHS back by three years.

Andrew Lansley should be congratulated for his efforts to introduce greater competition into the NHS. The health secretary has today released a white paper that grants extra freedoms to foundation trusts, expands choice for patients and supports a genuine ‘social market’ through the introduction of meaningful competition law.

Recent evidence on the impact of the competition that already exists in the NHS points to improved managerial quality; reduced inequalities in access (in terms of waiting times); improved quality as measured by 30-day in hospital mortality from acute myocardial infection; and reduced length-of-stay.  This suggests the gains from competition could be greater if they were meaningful and that the direction set in the white paper is the right course of action to drive value in tight financial times.

However, moves to transfer responsibility for commissioning from primary care trusts to GPs universally and at such a rapid pace must be cause for concern.

What is proposed represents a huge structural change. The reality is that considerable resources will need to be devoted to the restructuring by: creating new organisations; laying people off in PCTs and recruiting new staff at GP consortia; working out the right blend of risk and reward for GP consortia; creating new accountability frameworks; and implementing new formulas for distributing resources.

All will take time, distract attention, and carry significant risks if it goes wrong. Evidence from past restructuring of commissioning in the NHS in 2006, published by Civitas, suggests an absolute dip in performance of at least one year is likely,  What’s more, the NHS can expect to be set back at least three years relative to what could be achieved without any structural change, which would be ruinous for the service’s goal of making £20bn efficiency savings by 2014.

It is also unlikely that it will cut management costs by 45%; with 500 commissioning organisations replacing 152, transaction costs, for one, will almost certainly increase. Many people, too, will end up re-applying for their old jobs in the new structures.

To complement moves on the provider side, instead of effectively eradicating PCTs, the coalition government should focus attention on developing PCTs' commissioning skills and getting behind them as vigorous, impartial purchasers of care, able to exert pressure on providers to improve, or to switch services where necessary to new innovative ones (NHS or non-NHS) without fear of backlash. The goal of increasing clinical involvement in commissioning is vital to this, but would be better achieved working through existing structures.

James Gubb is director of the health unit at the Civitas thinktank

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