Insider view: Lyn Whitfield

As the immediate past president of the Royal College of General Practitioners, Professor Steve Field has spent half a lifetime working on NHS policy.

Yet when he arrived at the King’s Fund to present the results of the Future Forum’s ‘listening exercise’ on the latest government’s plans for reorganisation and reform he sounded like a man with a renewed enthusiasm for his subject.

Journalists attending the Forum’s press conference were handed piles of photocopied reports on everything from choice and competition in the health service to educating and training its staff.

Indeed, Professor Field would have liked more working groups; and his repeated references to IT, electronic records, and new information services for patients suggested this was one area he would have liked to explore in more detail.

On the way to the forum

Overall, his highly personal ‘Summary report on proposed changes to the NHS’ set out a vision of a more integrated health and social care service, focused not on acute care but on long term conditions and prevention, in which staff and patients would have a louder voice.

Unsurprisingly, he agreed with those who found that the Health and Social Care Bill that is meant to enact the ‘Liberating the NHS’ reforms contained too few safeguards to stop private companies disrupting care pathways and ‘cherry picking’ easy and profitable services.

As an alternative, he laid out a new model - with diagrams - in which the health secretary would give the new NHS Commissioning Board the job of setting a ‘choice mandate’ that explained where choice and competition should fit into care pathways.

Monitor would have the job of regulating the sector and making sure that everybody played by the rules. Citizens would keep an eye on the mandate and Monitor through a new Citizen’s Panel attached to HealthWatch England; and get an individual ‘right of challenge’ if they were denied choice or good services.

Commissioning consortia would still be led by GPs, but they would have to have a governing body with a lay chair or deputy chair, as well as nurse, consultant and other professional representatives. They would also have to meet in public; as would providers, including NHS foundation trusts.

Great Guy’s

The problem faced by Professor Field and his 44 experts was that while they could come up with a vision for the NHS, the only vehicle available to them for trying to bring it about was to make recommendations for changes to the government’s pre-existing Health and Social Care Bill.

This they duly did in 16 ‘core’ recommendations. Most of which were accepted by the government. Which allowed Prime Minister David Cameron to go along to Guy’s Hospital and declare ‘job done’.

“You wanted us to make clear that competition isn't there for its own sake, but to make life better for patients – done,” he said, flanked by Deputy Prime Minister Nick Clegg, health secretary Andrew Lansley, a group of hand-picked staff, and TV cameras.

“You wanted us to join up the different parts of the NHS, to put integration right at the heart of our reforms – done.”

However, it does not follow that because the government has accepted many of the Forum’s specific recommendations, it has bought into its vision. It would be perfectly possible for the government to incorporate the core changes into a revised health bill, and still create a more competitive NHS, driven by choice rather than voice, in a few years’ time.

A lot will now depend on exactly how the Bill is phrased; and which of the new bodies that it creates get the money, staff and backing to work effectively.

Useful ambiguity

Take, for example, the changes that the Department of Health’s response to the Future Forum’s report make at the top of the NHS.

The response says the health secretary will retain “ultimate responsibility” for the provision of health services; although he will this by holding the NHS Commissioning Board and other bodies to account.

This suggests the health secretary will need a fairly big department to decide what the NHS Commissioning Board should do and how it should do it; which suggests there will be plenty of scope for power struggles between the two bodies.

This week it was confirmed that the NHS Commissioning Board will be based at Quarry House in Leeds; which is hardly an encouraging precedent. Quarry House was built for the old NHS Executive, which was sent off to Yorkshire to demonstrate its independence from Whitehall.

Senior staff spent their time shuttling back and forth to London and securing offices – no matter how small – in Richmond House; because that is where ministers and their advisers stayed.

Or take the new role for Monitor. The DH response says “Monitor’s core duty will be to protect and promote patients’ interests.” What constitutes “patients’ interests” is anybody’s guess; and will differ according to the views of the person doing the guessing.

Specifically, the response says that Monitor will now be “limited to tackling specific abuses and unjustifiable restrictions that demonstrably act against patient’s interests and ensure a level playing field between providers.”

Yet a powerful Monitor, backed by a government that felt any restriction on patient choice or competition was “demonstrably against patient’s interests”, could still find a lot of work “tackling specific abuses.” And NHS providers might or might not find much comfort on finding themselves on a “level playing field” with others.

In this context, it’s worth noting that the “additional safeguards” against cherry picking have still to be outlined; and the government is strengthening other drivers of competition, such as personal health budgets.

This level of ambiguity is not easy to get across in a news bulletin, which is, presumably, why so many commentators wanting to know whether the Future Forum backed the government or not have cried “fudge” over the outcome of its work.

BMA chair Dr Hamish Meldrum certainly understood it, when he said he wanted to see the bill and pointed out that "the success of the reforms will very much depend on how the various elements link together and work on a practical level."

Unfortunately, it will take a long time to find that out. For those working in the NHS – including those working in its IT departments and services – the immediate effect of Professor Field’s work is likely to be more turmoil and uncertainty. For those trying to supply services to the NHS – including consultancy and IT systems – it is likely to mean the same.

More uncertainty ahead

It looks as if the government will redraft its Health and Social Care Bill and take it back to its report stage. It might take until the autumn to get it back through its committee stage and ready to send to the Lords – the point at which it was ‘paused’ ten weeks ago.

At worst, it could be the spring before it becomes law. To take account of this, the DH’s response says that strategic health authorities will be formed into ‘clusters’ this year, ready to become “local arms” of the NHS Commissioning Board.

Primary Care Trusts will be abolished on schedule in April 2013; but not all Clinical Commissioning Groups will have been “authorised” to take on full budgetary responsibility by then.

It is not clear whether CCGs that are only “part authorised” or operating in shadow form will be able to take on other statutory duties, hold employment contracts and so forth; creating a new layer of uncertainty for people hoping to be employed by or to win contracts from them.

The DH response does say that CCGs that aren’t authorised will have the “local arms” do their commissioning. But this will surely mean delays to some of the big budget and reconfiguration decisions that need to be made if the NHS is going to have any chance of meeting the ‘Nicholson challenge’ to find £20 billion efficiency savings over the next four years.

After all, SHAs do not have this kind of commissioning expertise at the moment; and even if the “local arms” can find it from somewhere, they are unlikely to re-jig pathways when they know Clinical Commissioning Groups are waiting to do the job.

Delays of this kind could also mean delays in getting IT in place to deliver the kind of integrated service that Professor Field wants. Indeed, with two lots of commissioners in play, it is highly likely that providers will instead look to protect their existing positions by playing one off against another.

The fact that the DH response says this should not happen shows just how likely it is that it will. Finally, on the provider side, the push to make all trusts foundation trusts has effectively been put back two years to April 2016; supposedly to make sure their governors are ready.

Plans needed

Now there is some certainty, though, it would help NHS IT and informatics staff if the DH informatics directorate could issue the plans it says it has been forming to help NHS IT transition from the old NHS to the new.

As a number of EHI commenters have pointed out, it would also be useful to have the information and technology strategies that were ‘paused’ with the Bill. Unfortunately, while the political wrangling continues, there is no sign of them.