Just imagine it’s October 2012 and your left foot is really painful – as in keeping you awake at night. In October 2011 it was your right foot that hurt and your doctor sent you to the local NHS hospital for treatment at its podiatry clinic (for foot health - more than chiropody.)
By October next year, your doctor might well offer you a choice for treatment for your left foot – by your local NHS hospital, by a charity, by a social enterprise group or by a commercial company. Podiatry was one of the services the government wanted put in the fast lane to provide competition to the NHS and choice for the patient by October 2012.
When Health Secretary Andrew Lansley first launched the policy he called it “Any Willing Provider”. It’s now somewhat more reassuringly called “Any Qualified Provider”. We are not re-entering the era of snake-oil salesmen. But we are entering unknown territory.
The timescale is tight. NHS Wiltshire were told late in July that they had to complete consultation by the end of September on the government’s list of eight possible services. So on September 12 they held a Stakeholders’ Assembly - gathering about sixty-five local professionals, councillors, representatives of charities and patient groups and some of the doctors involved in the new commissioning groups to help select the first three or more services.
After much discussion three services came to the top of the list: treatment of neck and back pain (physiotherapy plus), direct access diagnosis (blood tests and more) and memory clinics (for those in the earlier stages of conditions such as alzheimer’s.) As it turned out, podiatry was one of the services least favoured to be part of the first round of setting up competitive providers – so your left foot’s safe with the NHS till well after October 2012.
Two other services – developmental disorders (ADHD and autistic spectrum conditions) and lymphodaema (swelling caused by lymph problems) – may come into the frame once more work has been done on how they could fit with related treatments and how to specify their work.
There are, of course, a great many hoops for any potential rival provider to go through. Are they a credible outfit – with financial stability, appropriate legal status and so on? Will they improve the service to patients? Can they find the right staff? Can they respond to referrals from GPs fast enough? What about training?
One thing is certain: there will be no protection for any kind of provider - government policy focuses primarily on effecting choice. This is a “very explicit political judgment on how to improve the NHS.”
All this will most likely bring added headaches for GPs and their colleagues in the new commissioning groups which will take over the budgets from the primary care trusts. First it will make control of the budgets much more difficult – even precarious. Secondly it may often face GPs with conflicts of interest.
Will they advise patients which treatment to choose when that choice may well affect the commissioning group’s bottom line? We may well see the rise of “patient advisers” attached to surgeries to help patients choose.
Those advisers and the complexity of overseeing and checking the new providers, tracking fragmented sources of cost and keeping clear of the clutches of competition umpires, will all involve a host of backroom jobs – or, as the government likes to call them, bureaucrats. And this at a time when most of the savings from the coalition’s radical NHS restructuring are supposed to come from ‘cutting bureaucracy’.
And no one can foresee precisely how the new commissioning groups will be able to make these services a satisfactory part of continuing and integrated treatment of their patients.
GPs and commissioning groups will be open to scrutiny and public shaming by the competition tsars that want to give non-NHS providers every chance to succeed. This is already happening with the choice of providers for elective surgery (such as hip replacements) – see Marlborough News Online’s earlier story.
There’s evidence already that social enterprises and charities will not get any favours in this process – in fact the risks in size and sustainability they bring to the NHS may doom them.
The social enterprise, not-for-profit group Central Surrey Healthcare (CSH) has been running community health for a large area of Surrey since 2006. Last year David Cameron presented them with the first ever Big Society award – a recognition that CSH’s 770 entrepreneurial nurses, therapists and other community staff have been providing quality care for less money. Even the Cabinet Office said CSH are delivering substantial improvements in quality and efficiency.
But when CSH bid for a new £500milion contract to spread their work to more of Surrey’s patients, Surrey primary care trust decided to hand the contract to Assura Medical Limited (75% owned by Virgin.) It seems the main reason was that CSH could not raise enough money for the necessary surety bond.
Has this decision put money before quality of service? CSH’s own contract comes up for tender in the next twelve months. The fear is the coalition government’s rules will favour another bid from a private, capital-rich company and dish the social enterprise workers.
And bearing in mind the experience of the health workers of Surrey, will charities and social enterprises in Wiltshire be successful when they make smaller scale bids for services under the ‘Any Qualified Provider’ label?
As the coalition government’s plans to bring radical change to the NHS advance by fits and starts, it’s now clear how Wiltshire will be divided into the newly termed “Clinical Commissioning Groups” (CCGs) – which just a month ago were called “GP Consortia”. These groups will be given most of the county’s NHS budget which is currently administered by the Primary Care Trust (PCT) – in our case by Wiltshire NHS which is due to be abolished after April 2013.
At the start of the government’s reform process, Dr Helen Kingston (pictured left) wrote the application for what were then five Wiltshire GP consortia to start the process toward official formation. Now she has told Marlborough News Online that there will be just three CCGs in Wiltshire.
The Marlborough Medical Practice will be part of the CCG that brings together the East Kennet (Marlborough, Great Bedwyn, Burbage, Pewsey and Ramsbury practices) and the North Wiltshire areas. It stretches from Corsham in the west to Ramsbury in the east, south to Pewsey and north to the border with Swindon. It will take in a population of about 167,000 out of Wiltshire NHS’ total of 455,450 people.
[The other two CCGs are Sarum – the south and south-east of the county based in Salisbury. And the CCG temporarily known as WWYKD – pronounced ‘wicked’ – which includes west Wiltshire, Yatton Keynell and Devizes. Dr Kingston is joint chairman of this CCG.]
Dr Kingston, who studied at King’s College, Cambridge, and trained in Oxford and Bath, qualified as a GP in 1990. She’s a partner in the Frome Medical Practice which has a branch surgery in Warminster. And she’s now working with lead doctors in the three groups on some Wiltshire-wide plans.
Dr Kingston acknowledges that there is a ‘tension’ between the demands stressed in the government’s health White Paper that the new structures to deliver the modernised NHS must be local and the whole service ‘patient centred’, and the tight state of the public finances. She says there’s a difficult balance between being small and ticking the ‘local’ box and the need to find economies of scale to achieve the huge and obligatory savings within the NHS.
With that in mind, the three Wiltshire CCGs are moving towards setting up an ‘over-arching’ organisation to provide essential management and administrative back-up right across the county. Some will undoubtedly say this looks like the ghost of the PCT.
Others will whisper that it might even mean that eventually there will be just one CCG for all Wiltshire. And that would not look good for a government that has made so much of its drive towards localism – pushing decision-making further down the democratic ladder.
Dr Kingston takes a positive view of the coalition government’s response to the parliamentary ‘pause’ and ‘listening process’ that followed the trenchant criticism – from within the health service and from outside – of Health Secretary Andrew Lansley’s original plans. She’s especially pleased with the new attitude toward managers - no longer seen as a “waste of space”.
She also backs the switch from the reliance on competition towards more “co-operation and coordination” to find the best ways to treat patients and improve care. The ‘year zero’ approach of the White Paper has gone: “Lots of good things are happening already [in the NHS] – let’s not throw the baby out with the bath water.”
However she does admit that the drawn out uncertainty amongst so many NHS employees is not good: “We need the new order put in place so we’re not distracted.” And she explains that the silence on the changes from the groups isn’t because people at local level “haven’t made up their minds, the structures haven’t been decided centrally yet”.
The process of these reforms has been slowed considerably – perhaps Andrew Lansley (pictured left) thinks of it as another over-long waiting time for treatment. And the new governance requirements for the CCGs are putting extra layers into the structure – in Dr Kingston’s words “frameworks and frameworks within the frameworks.”
“If the governance arrangements become very complex – it would drive us towards a larger grouping – because the infrastructure and expertise to manage it would need to be of a higher calibre and the resources for that would become too costly for small groupings.”
There’s that hint again that in the future they might need to be a single CCG for Wiltshire – the ghostly PCT walking abroad again.
But she fully acknowledges that, even when reinforced by boards that will include a hospital doctor, a registered nurse and two lay members, the new groupings of GPs will be responsible for such huge sums of taxpayers money that they must be seen to be properly set-up and accountable.
The Wiltshire’s CCGs’ next hurdle is for their business plans, accountability and governance structures to be signed off by the PCT at its July board meeting. If the PCT is satisfied they will become ‘interim CCGs’.
Final authorisation can only come in 2012 once the new NHS Commissioning Board comes into existence and has its say on what the government calls the groups’ “skills, competences and behaviours to do their job well. Skills that they will need to be able to commission high quality care within their allotted resources” [from ‘Government response to the Future Forum report’ – 3.93.]
There are now a lot of people whose official job – never mind the journalists, politicians and busy-bodies – will be to peer over the GPs’ shoulders and make sure they’re doing the job properly. And then, of course, there’s the public, the patients.
The government’s new plans for the CCGs put a tremendous onus on them to involve “patients and the public in their commissioning decisions”: “Clinical commissioning groups will be required to consult on their annual commissioning plans to ensure proper opportunities for public input…[and] will have to involve the public on any changes that affect patient services, not just those with ‘significant’ impact.” [from ‘Government response…’ - 4.41.] (That would certainly include any future changes to the use of Savernake Hospital.)
Dr Kingston is determined to have proper consultation processes in place: “Most people will be happy if there’s transparency. We have to explain prioritisation and then be consistent. We have to have very careful communications with the public.”
“People would get understandably cross if they thought they’d get a different treatment in a neighbouring practice. This involves consulting people before decisions are taken.” And for consultation she wants a reference group of the public in her area to include a “broad range of ages, geography, jobs and a balance of the sexes.”
The coalition government’s basic idea for its reorganisation of the NHS in England is that responsibility and budgets for commissioning health care will move from the Primary Care Trusts (PCTs) to groups of GP practices – or local ‘consortia’.
When the scheme is up and running, a consortium will have the budget to provide a hip replacement operation and will find the best place within that budget for the patient to have the operation. In doing so they will have to balance the expertise available and its costs with the patient’s newly strengthened right to choose their treatment.
As plans for our local consortium are worked out, Dr Jonathan Glover of the Marlborough Medical Practice will be attending the negotiation meetings in place of Dr Richard Hook who is about to take a sabbatical. Dr Glover told Marlborough News Online about the advice they’ve been given about their consortium’s size.
“So far we have been advised that the bigger the better. The more patients you have in your commissioning group, the louder your voice and the more say-so you will have about what you can ask on your patients’ behalf locally.”
The precise map of the consortium to serve the Marlborough area is not yet settled. But it looks as though the consortium will stretch from Ramsbury in the east to Corsham, Yatton Keynell and Sherston in the west and run south to take in Pewsey. It may even include Devizes.
That’s large – larger than the ‘local consortia’ the White Paper signalled.
“Snap. I was really quite excited about the prospect and thought that what we were going to have was perhaps the equivalent of a slice of cake coming out of Swindon with Wroughton, Chiseldon, Ramsbury, Bedwyn, Burbage, Pewsey and Marlborough. I was really quite excited about a consortium of that size with maybe a hundred thousand patients, but in effect we’re going to be more like 180,000 patients.”
“But the advice from the rest of the country is that if you are much smaller than that you won’t have a voice.”
It is also thought the size of consortia is being set by the need for economies of scale to achieve the government’s promise to cut NHS admin costs by 45% over the next three and a bit years. The average size of consortia already set-up is about 200,000. One in Somerset is said to involve 76 practices and cover 539,000 people and, at the other end of the scale, the one serving the Newquay area of Cornwall covers just 28,000 people.
When the reorganisation was launched, GPs were told that they’d have to take over commissioning whether they liked it or not. As Dr Glover puts it:
“If there’s a ship going, it’s better it leaves with you than without you. So it doesn’t entirely have our blessing but we feel that if it’s going to happen we want to have more of a steering than a passenger role.”
“That’s the reason for our involvement – not because we give it our wholehearted blessing but we feel it’s going to happen anyway.”
Dr Glover is “twitchy” about Health Secretary Andrew Lansley’s open support for the wide privatisation of services: “He’s pro it – that needs reining in a little bit.”
And although the NHS Bill’s progress through parliament has been put on pause by the prime minister, work on forming the consortium continues.
“We’re carrying on simply because standing still and waiting for the politicians to make up their minds isn’t really a viable option. We need to be, in part, driving a change if anything’s going to succeed.” The alternative would be “a wishy-washy change that is subject to failure because of lack of drive.”
So far the consortium is being funded by a payment of £2 per patient. It’s not yet clear whether this is a one-off payment. There’s also money available from the savings GPs are currently required to make – some of which will go towards the new admin costs.
2011 is supposed to be the year the consortia shadow the doomed PCTs. So consortia will soon have to start employing people and setting up headquarters.
“You recruit the best team you can and reward them appropriately. Some will be GPs, some existing practice staff and some will come from PCT staff.”
How would Dr Glover react if after this unusual pause in the Bill’s progress, changes were made to get it through the House of Lords that included putting councillors or patients’ representatives onto the consortia’s executive boards?
“I think that’s going to happen anyway. I don’t think that’s out of the question. I don’t know the mechanism, but I’d have no beef with proper community representation - even with voting rights.”
The coalition’s health White Paper laid great stress on putting ‘patients at the heart of the NHS’ stating that ‘Shared decision-making will become the norm: no decision about me without me.’ Might not this cause some bitter conflicts between patients and doctors as choice hits the budgetary wall?
“I think we’re quite well placed as GPs to explain about budgets. The difficulty comes when the change made to one patient’s treatment is there to facilitate another patient’s treatment and that’s where patients will undoubtedly question our decisions – which is everyone’s right.”
So far there are no details of how patient participation groups (which Lansley wants to call Local Involvement Networks or LINks) will be set-up. But Dr Glover believes they must be designed with real ‘teeth’.
Whenever there’s change in this area’s health services the question arises about the future of Savernake Hospital: “We don’t know what’s happening with that at all. It’s much too early. Suffice to say that as a practice we’d like much greater use made of it.”
Dr Glover told Marlborough News Online that from July more use is to be made of it. The out of hours service will be extending the duty doctor’s time there and will be basing a visiting car at the hospital too. This is a re-balancing of the out of hours care between the areas covered from Swindon and from Marlborough.
But Dr Glover adds: “I don’t think we’re going to be given the free rein to run Savernake.”
Top to bottom reorganisation of a huge and multi-layered, multi-skilled body such as the NHS in England is vastly complicated. Dr Glover explains that because of the pause for listening to people’s doubts about the Bill before parliament – if not for re-thinking it – the area’s GPs need to take care as they carry on making their plans.
“We need to be sensible about what we do and not incur excess expenditure in progressing change which might be rewound later. But we still need to look at devising a consortium because otherwise the time will be upon us and we won’t be ready.”
“Even though the political process has -- I don’t think it’s reached an impasse but it’s run into treacly sort of ground and we’re going to have see what happens over the next months.”