Lansley aims to end doctors’ criticism of the coalition’s NHS Bil

Written by Tony Millett.

The health secretary, Andrew Lansley has sent (February 16) an email to the “leaders of all prospective clinical commission groups (CCGs)” reassuring them they’ll be fully in charge of commissioning health services in England once the primary care trusts are abolished in March 2013. This follows criticism from GPs that too many regulators are being put in place to oversee their new commissioning duties and that their freedom to commission will be much reduced.

As Marlborough News Online has reported, some local GPs have voiced this criticism and following our reports a copy of Mr Lansley’s email has been forwarded to us.  It seems to reflect the government’s anxiety that they may be losing the argument over their NHS reforms.

The email opens: “I am writing to you to set out the important freedoms you can expect when the Health and Social Care Bill is passed into law and when CCGs take on their full statutory responsibilities. You will no doubt be aware of some of the interest the Bill’s return to the House of Lords is attracting in the media. This is not unusual for high-profile legislation, and I would like to reassure you that the Government remains fully committed to the successful passage of the Health and Social Care Bill.”

Mr Lansley then gives his reassurance to CCG leaders on three main counts:

“1. You will have the freedom, with your new powers and responsibilities, to commission services in ways that meet the best interests of your patients.”  He tells the GPs: “It is a fundamental principle of the Bill that you as commissioner, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests.”

This is a remarkable u-turn as from the general election onwards Mr Lansley and the Cooperation and Competition Panel have been telling commissioners when and how to put services in the hands of various kinds of private provider – what this government used to call ‘Any Willing Provider’ and then changed to the softer ‘Any Qualified Provider’.

“2. You will have the freedom to work with whoever you want to in commissioning health services.”  This section of Mr Lansley’s email is all about the fears that the CCGs’ support services – such as payroll, record keeping and analysis, HR and financial control, all work previously done within the PCTs – will in future be carried out by large privatised companies which will to all intents and purposes take over the commissioning work.

This refers to the widely voiced criticism that the CCGs, sometimes clubbing together to pay for support services, will merely be reinventing PCTs, just on a slightly smaller scale.

Mr Lansley puts the onus firmly onto the GPs: “Whatever commissioning support arrangements you choose, you will always retain responsibility as a CCG for the commissioning decisions you make – the Bill does not allow these decisions to be made by other bodies.”  This, of course, provides cover for other parties to put forward commissioning plans – so long as they are signed off by CCGs.

“3. You will be free from top-down interference.”  Mr Lansley tells the GPs leading the CCGs that they “…will have the legal responsibility for the NHS budget entrusted to you from April 2013 onwards, and the legal power to use it in the interests of your patients.”

In fact the CCG leaders will not have responsibility for the NHS budget for England – as a quarter of it or about £20 billion will be kept back and used by the NHS Commissioning Board for, amongst other things, directly commissioning primary care and specialised services – and to create a system to  ‘oversee ’ the CCGs.

Mr Lansley also tackles the criticism he’s heard from some CCGs that the clinical senates (which he writes without capital letters) being set up in response to last summer’s re-think on the Bill, will not be able to ‘second-guess the decisions you take.’  He reassures the GPs that these ‘senates’ will only “advise both CCGs and the NHS Commissioning Board on clinical issues at a broad strategic level.”

There are two elements of the coalition government’s policies for the NHS in England that are not mentioned in Mr Lansley’s email.

First, there is no mention of the local authority-based Health and Wellbeing Boards (H&WBs).  These are supposed to be responsible for assessing the health needs of their whole area – rather than just the needs of the area covered by each CCG.

The policy in the coalition agreement was to elect people onto the PCTs to give, as the Lib Dems wanted, democratic legitimacy or accountability.  When Lansley suddenly decided to abolish PCTs, the Lib Dems needed to find some other way of getting their democratic legitimacy.  They chose the H&WBs.  But as the Bill’s is written only one elected councillor has to serve on each of these Boards (this may be increased by amendment in the House of Lords.)

However, this appeased the Lib Dems’ demands for democratic input. The precise role of the H&WBs and their place in the new hierarchy of quangos is still not clear.  It is well known that some councillors thought the H&WBs would allow them to commission NHS services.

Mr Lansley’s words of support for the CCGs make it quite clear the Boards will do no commissioning. And their omission from Mr Lansley’s email makes it unlikely they will ever be a threat to the ‘freedoms’ promised to GPs and their CCGs.

The other startling omission is that there is no mention at all of Mr Lansley’s mantra for patient power which featured so clearly in the White Paper that preceded the Bill: “No decision about me without me.” In the world of GP power that Mr Lansley portrays in his email, the role of the patient has disappeared.

This is almost certainly because some GPs in the CCGs had begun to see a nasty conflict of interests between what patients would want and what the GPs would want to commission.

In case GPs leading CCGs really were beginning to feel unloved, Mr Lansley has soothing words for them: “Your desire to improve services stands as testament to your dedication as public servants. In return, the Government will hold true our word to give you the powers and freedoms you need to deliver better services for patients.”

As one doctor expressed it to Marlborough News Online, some doctors feel they are being set up to take the blame when the money runs out for the NHS.  Will they then be seen as ‘dedicated public servants’?  Others believe there will be conflicts of interest with some GPs taking advantage of the reforms to bring more work into their surgeries, so earning themselves more money. Will they then be seen as ‘dedicated public servants’?