The government has paused and listened to criticisms of the Health and Social Care Bill. But has the second opinion worked?
When the NHS white paper was published a year ago, it diagnosed three main pathologies for which major reform was the prescribed solution: weak commissioning; insufficient competition and choice; and excessive micromanagement from the political centre.
The prescription set out an array of medicines to deal with these ailments including: GP commissioning ‘consortia’ in place of primary care trusts; an economic regulator to promote competition among ‘any qualified provider’ of NHS-funded services; and a new more strategic role for the Secretary of State, with more power and responsibility vested in an independent NHS Commissioning Board and local health and wellbeing boards.
A stream of very public protest and criticism followed, causing the government to announce an unprecedented two-month ‘pause’ in the legislative process, during which it committed to listening to these concerns.
And this they did. GP commissioning is now to become ‘clinical commissioning’ and involve a wider range of professionals through clinical senates and networks, and with specialists and nurses formally part of consortia boards. Monitor will have a duty to promote the integration of services and to focus on preventing anti-competitive behaviour, rather than promoting competition as ‘an end in itself’.
But how different is this prescription for the NHS? Is this a case of replacing branded with (in effect the same) generic medicines, or does it represent a truly different therapeutic approach?
On commissioning, the move to a more inclusive approach with specialists working closely with GPs may offer the potential for local providers to work together in new ways to develop forms of integrated care like those explored in recent Nuffield Trust publications.
Another reading of the latest approach to clinical commissioning would be that in its desire to increase the local accountability of GP commissioners, it has prescribed a range of checks and balances that risk stifling the initiative and enthusiasm of the very people it was supposed to ‘liberate’.
On competition and choice, the devil will surely be in the detail of how the policy proposals are implemented, and the way in which the new NHS Commissioning Board and Monitor interpret their role and decide how far to encourage commissioners to offer a wider range of services and care pathways at a local level.
The lingering ambiguity about these issues is examined in the Nuffield Trust’s response to the Public Bill Committee on the proposed amendments to the Health and Social Care Bill, where we call for greater clarity, in particular about how far the NHS will be subject to EU competition law or not.
Finally, one has to think hard about the primary challenge facing the NHS, this being not commissioning, competition, or control, but a need to make unprecedented efficiency savings of 4% per year for the next five years.
Whilst local commissioning will clearly go some way towards developing the very different forms of care needed to address the health requirements of an ageing population with ever more complex needs, it will struggle to make the very difficult and unpopular decisions needed to extract major efficiencies.
In Managing the Transition Nuffield Trust chief cconomist Anita Charlesworth and I set out the scale of this challenge for managers in the NHS, and warned of the importance of keeping the NHS safe from both a financial and, most importantly, patient service, point of view
The government has listened and responded. What we do not yet know is whether the response is sufficient to address the primary diagnosis of financial challenge, a diagnosis that is likely to require major surgery for some parts of the NHS, in the form of service reconfiguration. Only when this has been confronted will the other remedies of commissioning and competition be able to take effect.
Judith Smith is head of policy at the Nuffield Trust
